Bleb reconstruction using donor scleral patch graft for late bleb leak and hypotony

Abstract

Purpose

Bleb dysfunction may occur as a late complication following glaucoma filtration surgery. Over-filtering, thinning and cystic blebs can lead to hypotony, leak and corneal dellen. We report our surgical management and outcomes of this specific entity using donor scleral patch grafts.

Methods

This is a 10-year non-comparative, retrospective interventional case series. Bleb reconstruction involved excision of encysted conjunctiva and sclera to identify the original fistula. A functioning donor scleral patch graft was sited over this with fixed and releasable sutures and the conjunctiva advanced. Intraocular pressure, visual acuity and post-operative issues were assessed.

Results

A total of 18 eyes of 17 patients with mean age 65 years (standard deviation 13.5) were included. Trabeculectomy was the primary procedure in 72% (n = 13) and deep sclerectomy in 28% (n = 5). Bleb leak accounted for 61% (n = 11), hypotony 33% (n = 6) and corneal dellen 6% (n = 1). Mean pre-operative intraocular pressure was 7 mm Hg (standard deviation 4.6) which increased to 18.5 mm Hg (standard deviation 12) at day 1 (p < 0.001), 11.8 mm Hg (standard deviation 4.6) at 3 months (p < 0.05), 12.1 mm Hg (standard deviation 4.2) at 1 year (p < 0.01) which was maintained at 12.1 mm Hg (standard deviation 5.3) at last follow-up (p < 0.001). Post-operative interventions included bleb needling, re-suturing, suture removal, further glaucoma management, bleb leak and cataract surgery. Visual acuity also improved post-operatively and was maintained.

Conclusion

Reconstruction of the filtering bleb architecture with donor sclera results in improved intraocular pressure while maintaining visual acuity. Post-operative care is required to support the restored bleb function. Our findings support the use of scleral patch graft as an effective and safe method for the long-term management of hypotony and bleb leak as a late complication of glaucoma filtration surgery.

Keywords

Cornea/external disease glaucoma glaucoma incisional surgery lens/cataract post-operative glaucoma/hypotony scleral degenerations surgery with high-risk ocular conditions

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References

Kirwan

Lockwood

Shah

, et al. Trabeculectomy in the 21st century: a multicenter analysis. Ophthalmology 2013; 120: 2532–2539.

Gedde

SJ.

Results from the tube versus trabeculectomy study. Middle East Afr J Ophthalmol 2009; 16: 107–111.

Edmunds

Thompson

Salmon

, et al. The National Survey of Trabeculectomy. III: early and late complications. Eye 2002; 16: 297–303.

Bindlish

Condon

Schlosser

, et al. Efficacy and safety of mitomycin-C in primary trabeculectomy: five-year follow-up. Ophthalmology 2002; 109: 1336–1341; discussion 1341–1342.

Nuyts

Greve

Geijssen

, et al. Treatment of hypotonous maculopathy after trabeculectomy with mitomycin C. Am J Ophthalmol 1994; 118: 322–331.

Wise

JB.

Treatment of chronic postfiltration hypotony by intrableb injection of autologous blood. Arch Ophthalmol 1993; 111: 827–830.

Cleasby

Fung

Webster

Jr , et al. Cryosurgical closure of filtering blebs. Arch Ophthalmol 1972; 87: 319–323.

Lynch

Roesch

Brown

RH.

Remodeling filtering blebs with the neodymium: YAG laser. Ophthalmology 1996; 103: 1700–1705.

Morgan

Diamond

Cook

SD.

Remodelling the filtration bleb. Br J Ophthalmol 2002; 86: 872–875.

10.

Schwartz

Robin

Wilson

, et al. Resuturing the scleral flap leads to resolution of hypotony maculopathy. J Glaucoma 1996; 5: 246–251.

11.

Costa

Arcieri

ES.

Hypotony maculopathy. Acta Ophthalmol Scand 2007; 85: 586–597.

12.

Scoralick

ALB

Almeida

Ushida

, et al. Hypotony Management through Transconjunctival Scleral Flap Resuturing: Analysis of Surgical Outcomes and Success Predictors. J Curr Glaucoma Pract 2017; 11: 58–62.

13.

Haynes

Alward

WL.

Rapid visual recovery and long-term intraocular pressure control after donor scleral patch grafting for trabeculectomy-induced hypotony maculopathy. J Glaucoma 1995; 4: 200–201.

14.

Prokosch-Willing

Lamparter

Ul Hassan

, et al. Results of an adaptive surgical approach for managing late onset hypotony after trabeculectomy with mitomycin C. J Glaucoma 2018; 27: 307–314.

15.

Maruyama

Shirato

Efficacy and safety of transconjunctival scleral flap resuturing for hypotony after glaucoma filtering surgery. Graefes Arch Clin Exp Ophthalmol 2008; 246: 1751–1756.

16.

Rauscher

Barton

Budenz

, et al. Long-term outcomes of amniotic membrane transplantation for repair of leaking glaucoma filtering blebs. Am J Ophthalmol 2007; 143: 1052–1054.

17.

Wadhwani

Bellows

Hutchinson

BT.

Surgical repair of leaking filtering blebs. Ophthalmology 2000; 107: 1681–1687.

18.

Mardelli

Bakkour

A novel hinged scleral patch graft for the repair of overfiltration and bleb leaks. J Glaucoma 2018; 27: 377–381.

19.

Sihota

Angmo

Ramaswamy

, et al. Simplifying ‘target’ intraocular pressure for different stages of primary open-angle glaucoma and primary angle-closure glaucoma. Indian J Ophthalmol 2018; 66: 495–505.

20.

Landers

Martin

Sarkies

, et al. A twenty-year follow-up study of trabeculectomy: risk factors and outcomes. Ophthalmology 2012; 119: 694–702.